Failure of a new antivenom to treat Echis ocellatus snake bite in rural Ghana: the importance of quality surveillance.

This study compares two antivenoms used to treat Echis ocellatus snake bite patients at Mathias Hospital, Yeji, central Ghana. FAV-Afrique antivenom (Aventis Pasteur) was given to 278 patients during 2001--2003, whilst Asna Antivenom C (Bharat Serum and Vaccines Ltd) was used in 2004 to treat 66 patients. The two groups had comparable patient attributes, time from snake bite to treatment and staff adherence to the tested treatment protocol. The antivenom C group required more repeat doses and twice the amount of antivenom to treat coagulopathy. Of greater concern, the antivenom C mortality rate was 12.1%, a marked rise from the 1.8% rate in the earlier FAV-Afrique antivenom group. In this study, antivenom C was ineffective as treatment for West African E. ocellatus snake venom. This illustrates the absolute need for regional pilot tests to assess the effectiveness of a new antivenom against local snake venoms before its sole and general distribution in a region is initiated.

Implementing preventive services. Success and failure in an outpatient trial.

Physicians endorse prevention but provide only low levels of screening, health counseling, and immunization. Between 1981 and 1986, a randomized controlled trial was conducted at the Seattle (Wash) Veterans Affairs Medical Center to assess the effectiveness of the following three methods of delivery of preventive services: (1) a physician-oriented model that includes education and motivation, a chart flowsheet listing recommended activities, and periodic feedback about performance; (2) a patient education model in which patients were mailed an informative brochure advising them to ask physicians for preventive services as depicted in a patient-held pocket guide; and (3) a health promotion clinic that patients were invited to attend. A control group received their usual care. A total of 1224 male outpatients were enrolled in the trial. Baseline prevention rates for 12 age-specific prevention activities were below 25%. Neither the control group rates during the 5-year trial nor the rates for the two educational models, either singly or as a combined intervention, changed. Only the health promotion clinic model was effective, tripling prevention rates in its first year and sustaining these levels for all 5 years. It is difficult to change the clinic roles of experienced physicians and their long-term patients in a specialized multiclinic setting. Providing a separate health promotion clinic option is popular with patients, bypasses gatekeeper barriers, is reasonable in cost, and warrants wider application.

Comparative clinical reliability of fasting plasma glucose and glycosylated hemoglobin in non-insulin-dependent diabetes mellitus.

Because accurate determination of glycosylated hemoglobin (GHb) is difficult and relatively expensive in comparison with the modest cost and ready availability for tests of fasting plasma glucose (FPG), we examined the reliability of repeated measurements of FPG and GHb in typical diabetic outpatients taken in the usual clinical setting. We determined FPG and GHb concurrently on three separate occasions spanning 4 wk in 41 patients with non-insulin-dependent diabetes mellitus (NIDDM) and, for contrast, 5 with insulin-dependent diabetes mellitus (IDDM). Most of the NIDDM subjects were obese, with initial FPG levels ranging from 93 to 355 mg/dl. The reliability of each test was estimated by calculating two measures: the intraclass correlation coefficient (rho I) and the coefficient of variation (CV) for the repeated test values. For NIDDM patients treated with diet or oral hypoglycemic agents (OHA), rho I for FPG, log(FPG), and GHb were very similar. For insulin-treated NIDDM patients, rho I for FPG was somewhat lower than the coefficient in other treatment groups, and the reliability of FPG by this measure did not match the reliability of GHb within the limits of statistical significance. By analyzing the CV of test values repeated within subject, the reliability of FPG did not differ from GHb in any of the NIDDM treatment groups. Although patients were recruited sequentially to minimize sample selection bias, caution must be exercised in the interpretation of the statistical analyses of reliability with either rho I or CV due to limitations imposed by small sample size.(ABSTRACT TRUNCATED AT 250 WORDS)

A household morbidity survey in rural Africa.

A household morbidity interview survey with 2,000 randomly selected households (14,729 people) in rural Ghana is reported for a two-week recall period; 20-8 percent of people reported some illness, injury or disability. This prevalence is lower than reported during surveys in Columbia, USA, Britain and Australia. Adults averaged 0-5 days lost from work, which results in an estimated annual work loss of 13-4 days. The reported illness varied markedly with age, with a peak in middle-aged adults and females in their reproductive years. The use of clinic services varied with age (they were sought particularly for pre-school children), type of condition, and accessibility. The use of drug sellers was surprisingly high, about half that of clinic attendance, and increased in those geographical areas where clinics were least accessible.

Failure of thiabendazole and metronidazole in the treatment and suppression of guinea worm disease.

Guinea worm disease is endemic in West Africa. In 1973 a field drug trial was conducted to compare effectiveness, cost, and side-effects of thiabendazole and metronidazole in treating active guinea worm disease and preventing latent worms from emerging. A mass chemotherapy campaign was planned to follow the drug trial. Only 15.5% of the treated patients expelled the worm completely, and in 28.4% of the cases worms continued to appear. Both drugs were equally unsatisfactory in their anti-helminthic effect. Consequently, our efforts to control guinea worm have shifted from chemotherapy to chemical control of cyclops and improvement of rural water supplies.

Endemic rabies in Ghana. Epidemiology and control measures.

Rabies is well established in Accra and there has been no decline in canine or human cases during the past 5 years. In the first 6 months of 1975, canine cases almost doubled over the period average. So far dogs are the only confirmed carnivorous vector in Ghana. A clear seasonal peak exists, so that intervention efforts can be times to achieve a maximum impact. Persons at greatest risk of contracting rabies are males and school-aged children, who need improved educational and post-dog bite services. The fundamental issue for health policy is to achieve a proper balance between environmental, preventive and treatment aspects of rabies. The report describes problems with logistics, canine vaccine shortage and failures, lack of owner cooperation, and control of a large stray dog population. Several proposals to improve coordination and organization of control programs are suggested.

Guinea worm in southern Ghana: its epidemiology and impact on agricultural productivity.

In southern Ghana guinea worm disease was found to occur almost exclusively in villages dependent upon pond water during the dry season. The recent occurrence of guinea worm for the first time in many villages in the survey area suggests that the disease is spreading. The risk of increasing disease in the Accra plains is serious, because almost half of the 159 villages surveyed use pond water, and residents frequently travel to endemic areas. In this study adult male farmers were at greatest risk of becoming infected. The average work loss in untreated adults was more than 5 weeks. Because guinea worm disease is seasonal, conciding with peak agricultural activities, and few alternative labor sources are available for the incapacitated farmer, a marked reduction in agricultural output occurs. Additional research is needed to guide health education programs, to evaluate the effectiveness of chemical control of cyclops in ponds, and to develop low-cost improved rural water supplies.

Comparison of morbidity interviews with a health examination survey in rural Africa.

This paper describes a study of the Danfa Comprehensive Rural Health and Family Planning Project, Ghana. The report compares information obtained from morbidity interviews with information obtained during subsequent health examinations. One to 4 days prior to examination by a team of physicians, 3,653 rural Ghanaians were interviewed by a team of auxiliary workers. Information obtained from the interview survey was noticeably different from examination diagnoses. Significant health problems such as malaria, intestinal parasites and diarrhea, as well as minor and chronic conditions were seriously under-reported. Interview findings were more accurate for children, women in the reproductive age group, and in cases in which the disease caused considerable discomfort or diability. Although individual examination was eight times as costly as an interview, small scale rural health examination surveys of a representative sample of the population are recommended to provide accurate morbidity information for health planners.

Meningococcal meningitis in northern Ghana: epidemiology and control measures.

Hospitalized meningococcal meningitis patients in northeastern Ghana during 1972-1973 were studied to provide baseline information about case clustering and age-specific attack rates to guide meningitis control programs. In 1973, group A meningococci were prevalent and 7% of isolates were sulfadiazine-resistant. In contrast to the age distribution of meningococcal meningitis in North and South America, peak attack rates occurred in 10- to 14-year-old Ghanaians. A mass immunization campaign using group A polysaccharide vaccine in heavily populated areas of the Bawku and Nalgerigu districts is recommended.

Protocol and monitoring to improve snake bite outcomes in rural Ghana.

A study was conducted in Mathias Hospital, Yeji, an area of Ghana, where snake bite cases are an important cause of morbidity and mortality, with a case fatality rate of 11% (8/72). Case management difficulties included uncertainty about the assessment of the severity of envenoming, the dosage of antivenom, and the response to treatment. An intervention with several components was introduced: development of a treatment protocol, staff training, monitoring of compliance and patient education. During a 33-month post-intervention period there was excellent protocol compliance, fewer snake bite complications, and a fall in mortality rate to 1.3% (3/238) compared with a 15-month baseline review. There was a 50% increase in snake bite admissions and fewer delays. To improve snake bite outcomes in comparable settings, particularly if inexperienced staff are involved in care, we recommend a similar quality assurance project, involving case review and use of a treatment protocol with monitoring of compliance to sustain an improved approach.

Endemic pyoderma in Ghana: a survey in rural villages.

The prevalence and characteristics of pyoderma in a randomly sampled rural population in Ghana has been studied. Findings are compared with studies reported in recent literature which describe pyoderma in other countries. In the present study, conducted in 1975 as part of the Danfa Project's Village Health Survey, pyoderma was diagnosed in 19.4% of villagers examined. Peak rates occurred in the five to nine-year-old age group, and pyoderma was more prevalent among males and unskilled labourers and farmers than among those engaged in more sedentary occupations. Non-bullous impetigo was most common (72% of lesions) and, in contrast to other studies, non-group A-streptococci predominated in these lesions (82% of streptococcal lesions were Group G, 18% Group C). Current knowledge of transmission and control of pyoderma is discussed.

Blood pressure distribution in a rural Ghanaian population.

Hypertension and related complications appear, from clinical impression, to be increasing problems in urban Ghanaians. In early 1973 we conducted a blood pressure survey in 20 rural Ghanaian villages to determine the prevalence of hypertension, in comparison with studies done in Accra residents and black Americans. Rural Ghanaians had mean systolic and diastolic blood pressures which were lower at all ages than the urban groups. 2-5% of the subjects aged 16 to 54 years had diastolic blood pressures of 95 or higher mm Hg. These findings are discussed in view of the proposed hypertension control programme in Accra. We conclude that hypertension is not a significant health problem in rural Ghanaians and that large-scale hypertension case-finding and intervention programmes should be confined to urban populations.

The accuracy of tuberculin skin tests: self-assessment by adult outpatients.

Tuberculin skin testing is an accurate, inexpensive screening procedure for detecting tuberculosis infection. The return visit needed to interpret the reaction is inconvenient, costly, and may contribute to under-utilization of the test. Although some clinicians ask patients to read their own purified protein derivative (PPD) test results, patient accuracy and the degree of teaching needed to learn this skill are unclear. This study evaluated the accuracy with which 145 outpatients read their own Mantoux skin test (PPD) reactions and reported by postcard after brief training by nurse practitioners. A total of 89 instructed patients returned postcards and also returned for clinician readings; 46 submitted postcards without returning; 7 returned but did not complete postcards; and 3 neither returned postcards nor returned for readings. Ten of 135 postcards were uninterpretable. For 81 subjects with both interpretable tuberculin self-assessment postcards and clinician readings, overall PPD classification agreement was 88 percent; Kappaw = +0.905 (P less than .001). Compared to clinician readings, 1 of 53 patients falsely reported a positive reaction (greater than or equal to 10 mm) and 2 of 25 patients falsely reported negative PPD readings (0-4 mm). There was 100 percent agreement between postcard readings and clinician classifications in a subgroup of patients (N = 26), prospectively identified by nurse practitioners as capable of accurate tuberculin self-assessment. Inter-clinician reading agreement (N = 37) was 89 percent; Kappaw = +0.943 (P less than .001). The brief standardized teaching protocol described can enable most patients to measure and report their PPD results. Study results suggest thatpostcard reports, especially negative ones, from a subgroup of patients selected for their skill in measuring their initial PPD wheal and ability to paraphrase instructions, might be substituted for clinician readings.

Are physicians obligated to provide preventive services?

Preventive care is considered a benefit to the patient. Physicians express a positive attitude towards prevention, but their performance of recommended activities is low, as shown in a five-year trial at the Seattle VA Medical Center. The release of the U.S. Preventive Services Task Force's guide to clinical preventive services has provided physicians with authoritative prevention recommendations. While most physicians are specialists with little interest or skill in preventive care, primary care providers do accept an obligation to provide comprehensive care, including prevention. This paper examines the ethical basis for the idea of obligation. External pressures, legal, economic, and organizational, are affecting the physician-patient relationship in ways that encourage a contract mode of medical practice and limit physicians' ability to provide preventive care. As a profession, medicine needs to speak for the health needs of the public. As practitioners, physicians need to seek the welfare of their patients.